A Pathway for Improving Performance and Interpretation of Strain in a Pediatric Echocardiography Laboratory

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BACKGROUND: Echocardiographic quantification of myocardial deformation is a valuable tool to assess left ventricular systolic function in children at risk for systolic dysfunction. Since clinical utility is dependent on accurate and reproducible data, pediatric echo labs should establish a process to ensure high quality strain performance and interpretation. We describe our institutional experience of a successful strain implementation pathway. METHODS: Starting in 2016, various plan-do-study-act cycles were implemented, including a comprehensive echocardiography function protocol, knowledge and skill-based education, updated equipment and software to optimize acquisition, reporting, and billing for global longitudinal strain (GLS). We reviewed a sample of echocardiograms annually from 2019 to 2023 on children at risk for chemotherapy related cardiotoxicity (CTRCD). We calculated the percentage of echocardiograms that performed and reported GLS, reviewing for accuracy. RESULTS: From 2019 to 2023, 685 echocardiograms were reviewed. GLS reporting increased from 39% in 2019 to 76% in 2023 and accuracy improved from 57% to 72% (p < 0.001). Reasons for inaccurate GLS included poor 2D image quality (24%), endocardial border tracing errors despite good image quality (45%) or both (21%). In almost half the studies where GLS was measurable but not reported [99/214; 46%], GLS had not been performed on the echo cart. Reporting of GLS improved from 27% in 2019 to 66% in 2023 with on-cart automation and easier post-processing; and other interventions, including iterative education. CONCLUSIONS: Implementation of administrative, technological, and educational interventions helps to establish a pathway of consistent, high-quality performance and accurate reporting of GLS in pediatric echocardiography labs.

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